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Embracing complexity: A consideration of hypertension in the very old
1Department of Internal Medicine, School of Medicine, and Sealy Center on Aging, The University of Texas Medical Branch, Galveston 77555-0460, USA. jsgoodwin@utmb.edu
Insights
In very old adults (85+), higher blood pressure is linked to better survival, and treatment may reduce efficacy. Further research is needed to understand hypertension management in the elderly.
Area of Science:
- Gerontology
- Cardiovascular Medicine
- Clinical Trials
Background:
- Hypertension management guidelines typically do not differentiate by age, potentially overlooking unique physiological responses in the very old.
- Existing research on hypertension treatment efficacy in younger populations may not translate to individuals aged 85 and older.
Purpose of the Study:
- To investigate the association between blood pressure levels and survival in individuals aged 85 years and older.
- To evaluate the efficacy and potential adverse effects of hypertension treatment in the very elderly population.
Main Methods:
- Analysis of survival data in relation to systolic and diastolic blood pressure in adults aged 85+.
- Meta-analysis of randomized controlled trials (RCTs) involving hypertension treatment in subjects aged 80 years and older.
Main Results:
- Higher systolic and diastolic blood pressure levels were associated with increased survival in adults aged 85+, independent of comorbidities and treatment.
- Three out of four RCTs showed reduced treatment efficacy for hypertension in subjects aged 80+.
- A meta-analysis revealed a 14% higher total mortality in the hypertension treatment group for individuals aged 80+ (p=0.05).
Conclusions:
- The conventional approach to hypertension management may require re-evaluation for individuals aged 85 and older.
- Stratifying older adults by physiological vigor in clinical trials is crucial for developing evidence-based treatment guidelines for hypertension and other conditions.
Abstract:
The consequences of hypertension and its treatment differ in very old men and women compared to younger populations. In populations aged 85 years and older, higher levels of systolic and diastolic blood pressures are associated with increased survival, and this relationship is not eliminated by controlling for comorbidity, blood pressure treatment, and other relevant factors. In addition, in 3 of the 4 published randomized controlled trials of treatment of hypertension that included subjects aged 80 years or older, the investigators reported loss of efficacy of treatment in preventing the primary end points in subjects aged 80 and older. In a meta-analysis of those trials, total mortality was actually 14% higher (p =.05) in the treatment group for subjects aged 80 years and older. These data suggest 2 conclusions. First, we should reexamine that dictum that nontreatment of hypertension in those aged 80 years and older is de facto evidence of "ageism." Second, we are unlikely to come to any set of coherent "rules" regarding treatment of hypertension (and several other conditions) in the very old until we routinely stratify all older subjects enrolled in interventional or observational trials by indicators of physiologic vigor.